Provider Demographics
NPI:1710790860
Name:FUENTES-MURILLO, JOHANNA (MS, LAC)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:FUENTES-MURILLO
Suffix:
Gender:F
Credentials:MS, LAC
Other - Prefix:
Other - First Name:JOHANNA
Other - Middle Name:
Other - Last Name:FUENTES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:598 CENTRAL AVE STE 7
Mailing Address - Street 2:PO BOX 482
Mailing Address - City:NEW PROVIDENCE
Mailing Address - State:NJ
Mailing Address - Zip Code:07974
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1110 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3403
Practice Address - Country:US
Practice Address - Phone:347-273-1290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-30
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00848500101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health